The nurse is caring for the client experiencing Guillain-Barre syndrome (GBS). It is most important for the nurse to monitor the client for which complication?

hyperglycemia

Urinary retention

Respiratory failure

Hypertension

Answer and Explanation

The Correct Answer is C

A. Hyperglycemia:
Although hyperglycemia can occur as a result of stress or corticosteroid use during the treatment of GBS (such as in the case of plasma exchange or IV immunoglobulin (IVIG) therapy), it is not the primary complication associated with GBS. While hyperglycemia requires monitoring and management, respiratory failure is a more immediate and critical concern.

B. Urinary retention:
Urinary retention can occur in some clients with neurologic disorders like GBS, but it is not as life-threatening as respiratory failure. The autonomic nervous system, which controls bladder function, may be affected, but urinary retention is usually manageable with intermittent catheterization or other interventions. It does not carry the same immediate risks to life or organ function as respiratory failure.

C. Respiratory failure:
In Guillain-Barré syndrome (GBS), the immune system attacks the peripheral nervous system, which can lead to progressive muscle weakness and paralysis. The most significant and potentially life-threatening complication of GBS is respiratory failure. This occurs because the paralysis can affect the muscles involved in breathing, including the diaphragm and intercostal muscles, leading to impaired ventilation. As the weakness progresses, the client may become unable to maintain effective breathing, requiring mechanical ventilation. Monitoring for signs of respiratory distress (e.g., increasing work of breathing, tachypnea, decreased breath sounds, or a drop in oxygen saturation) is critical in GBS, especially during the acute phase of the disease.

D. Hypertension:
Hypertension may be seen in some cases of GBS, particularly during the early stages of the disease, due to the autonomic dysfunction that can result from nerve involvement. However, hypotension (low blood pressure) is more commonly associated with the autonomic dysfunction in GBS rather than hypertension. Regardless, respiratory failure remains the most urgent complication to monitor for in clients with GBS.

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Correct Answer is B

Explanation

A. Tizanidine is a sleep aid and used to promote sleep along with melatonin:

This is incorrect. Tizanidine is not classified as a sleep aid. While muscle relaxants like tizanidine may cause drowsiness as a side effect, its primary purpose is to reduce muscle spasms rather than to promote sleep. Using it in combination with melatonin for sleep would not be appropriate unless specifically prescribed by a healthcare provider.

B. Tizanidine is a muscle relaxant medication used to reduce muscle spasms:

Tizanidine is a centrally acting muscle relaxant that is commonly used to treat muscle spasms and spasticity. In clients with amyotrophic lateral sclerosis (ALS), spasticity can be a significant symptom, leading to muscle stiffness and discomfort. Tizanidine helps by relaxing the muscles and alleviating the muscle tightness associated with ALS. It works by inhibiting nerve impulses that cause muscles to contract, thus reducing spasticity and improving mobility. This medication is not intended for sleep promotion or pain relief directly, but rather to manage muscle spasms.

C. Tizanidine is an antibiotic medication used to treat bacterial infections:

This is incorrect. Tizanidine is not an antibiotic and has no role in treating bacterial infections. It is a muscle relaxant used for managing spasticity, not an antimicrobial drug.

D. Tizanidine is an opiate and is used to relieve severe pain:

This is incorrect. Tizanidine is not an opiate and does not belong to the class of opioids. It does not have the pain-relieving effects of opioid analgesics. While it may provide some relief from muscle discomfort, it is not used to treat severe pain in the way opiates like morphine or oxycodone are. Tizanidine’s primary purpose is to address muscle spasticity, not pain management.

A. and record vital signs every 4 hours. B. intake and output hourly. C. heart and lung sounds every shift. D. level of consciousness every shift.

Correct Answer is B

Explanation

A. and record vital signs every 4 hours:
While vital signs are important, monitoring every 4 hours may not be frequent enough in an intensive care setting, especially for a client requiring mechanical ventilation. Vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, should be monitored more frequently (at least every hour) to detect changes in the patient's condition, particularly since positive pressure ventilation can significantly affect circulatory status.

B. Intake and output hourly:
In acute respiratory distress syndrome (ARDS), the client may require mechanical ventilation to support breathing. Positive pressure ventilation, while essential for improving oxygenation, can increase intrathoracic pressure, which may impair venous return to the heart, decreasing cardiac output. As a result, it is critical to monitor the fluid balance closely, as fluid overload can worsen the patient's condition and contribute to pulmonary edema or other complications. Hourly assessment of intake and output (I&O) helps the nurse monitor renal function, fluid status, and cardiac output. Maintaining a proper balance of fluids is crucial in managing ARDS and its associated complications.

C. Heart and lung sounds every shift:
A shift assessment of heart and lung sounds is useful but is not frequent enough to detect early changes in a client with decreased cardiac output or other complications related to mechanical ventilation. More frequent monitoring of lung sounds and heart function may be necessary, particularly in clients at risk of ventilator-associated complications like ventilator-associated pneumonia (VAP), pulmonary edema, or arrhythmias.

D. Level of consciousness every shift:
Monitoring level of consciousness is important, especially in clients with ARDS and mechanical ventilation, as changes in consciousness can indicate worsening hypoxia or hypercapnia. However, this assessment is less directly related to the immediate concern of decreased cardiac output, which can be more effectively managed through continuous monitoring of fluid status and vital signs rather than consciousness alone. Though consciousness should be monitored regularly, I&O hourly would be more crucial in this context for managing cardiac output.

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Arterial Blood Gases
pH	7.35-7.45
PaCO2	35-45mmHg
PaO2	80-100mmHg
HCO3-	22-26 mEq/L
O2 Saturation	>95%
Chemistry
BUN	8-21mg/dl
Creatinine	0.5-1.2mg/dl
Na	135-145 mEq/L
K	3.5-5.3 mEq/L
Cl	97-107 mEq/L
CO2	22-26 mEq/L
Ca	8.2-10.2 mg/dl
Glucose	65-99 mg/dl
Mg	1.7-2.2 mg/dl
PO4	2.5-4.5 mg/dl

The nurse is caring for the client experiencing Guillain-Barre syndrome (GBS). It is most important for the nurse to monitor the client for which complication?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client diagnosed with amyotrophic lateral sclerosis (ALS). The client was given a medical prescription for tizanidine. What information would the nurse provide regarding this medication? Tizanidine is

Correct Answer is B

Explanation

The nurse is caring for a client diagnosed with acute respiratory distress syndrome (ARDS) who requires mechanical ventilation. A client problem of decreased cardiac output from the positive pressure ventilator has been identified. What should the nurse include in the plan of care? Assess:

Correct Answer is B

Explanation

The physician orders 500 mg PO of medication. The Medication is supplied as a suspension 125 mg/5mL. How many mL will the nurse administer for one dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

The nurse is caring for the client experiencing Guillain-Barre syndrome (GBS). It is most important for the nurse to monitor the client for which complication?

The nurse is caring for a client receiving mechanical ventilation. The nurse hears the low-pressure alarm sound. After checking the client and ventilator, the nurse cannot determine the source of the alarm. What should the nurse do next?

The client diagnosed with multiple sclerosis (MS) is at risk for fatigue. Which priority intervention would the nurse implement to address this issue?

A client with a medical diagnosis of acute respiratory distress syndrome (ARDS) is being placed in the prone position. The nurse explains to family members that, "This will help improve ventilation by: